Raleigh Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Raleigh Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 18, 2023

  Based on record review, staff and Medical Director interviews, the facility failed to provide Activities of Daily Living (ADL) care safely to a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On [DATE] Nursing Assistant (NA) #1 began providing care to Resident #1 who was on an alternating air pressure mattress, she left the resident on his right side with the bed at waist height and exited the room to speak with the nurse and obtain supplies. While unattended, Resident #1 fell off the bed onto his back on the floor hitting his head, resulting in a hematoma (a pool of mostly clotted blood that forms in an organ, body tissue or body space) to the back of his head, shoulder pain, and left scalp pain. […]

• Immediate jeopardy, isolatedF689Jul 16, 2021

  Based on record review, staff interviews and interviews with a physician's assistant, and the hospital physician the facility failed to use 2 persons when transferring a resident with a mechanical lift according to the care plan for 1 of 1 resident (Resident #176) reviewed for accidents. The resident slid out of the lift pad onto the floor during the transfer and sustained multiple injuries that resulted in a spleen laceration, subarachnoid hemorrhage and rib fractures. The findings included: Resident #176 was admitted to the facility on [DATE] and had a diagnosis of multiple [CONDITION(S)] and age-related [CONDITION(S)]. […]

• Actual harm, isolatedF689Oct 12, 2023

  Based on record review, resident interviews, and staff interviews, the facility failed to safely transport a resident back to her room via wheelchair (Resident #5) when she requested to be put back to bed. Resident #5's left leg got caught under the left side of her wheelchair without leg rests attached while being pushed by a Nurse Aide (NA) and resulted in a nondisplaced fracture of the left proximal (near the center of the body) tibial (shinbone) metaphysis (neck portion of the long bone) and plateau (cartilage that covers the top end of the tibia). As a result, the resident endured acute (short-term) pain that was treated with medication. […]

• Actual harm, isolatedF867Oct 12, 2023

  Based on observation, record review, and interviews with resident and staff, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place in order to sustain compliance. This included a recited deficiency in the area of Supervision to Prevent Accidents (F689) as evidenced by repeat citations resulting in harm to residents. During the [DATE] recertification and complaint investigation survey, deficient practice at F689 resulted in the resident sustaining a spleen laceration, subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane) and rib fractures. […]

• Actual harm, isolatedF689Mar 22, 2023

  Based on observation, record review, and resident, staff, Nurse Practitioner and Medical Director interviews the facility failed to prevent a fall from bed during incontinence care. Nurse Aide #2 raised the bed to waist level to provide care and Resident #4 rolled off the bed to the floor after being turned on to her side. Resident #4 reported pain in her right thigh and denied hiting her head. Two days after the fall Resident #4 was sent to the hospital for evaluation due to tenderness on the right side of her head and temporary amnesia. A Computed Tomography (CT) of the head (a noninvasive medical exam or procedure that uses specialized X-ray equipment to produce cross-sectional images) was completed and noted a small subdural hematoma (collection of blood outside the brain). […]